Role of the renin-angiotensin-aldosterone system in diastolic dysfunction and heart failure

Heart failure with preserved left ventricular (LV) ejection fraction is commonly viewed as the consequence of diastolic dysfunction. Hypertension is the most common cause for the development of diastolic dysfunction and LV hypertrophy leading to symptomatic hypertensive heart disease. Strict blood pressure control therefore is mandatory to prevent diastolic heart failure in patients with hypertension. Besides the mechanical pressure load activation of the renin-angiotensinaldosterone system (RAAS) essentially contributes to the progression of LV hypertrophy and diastolic heart failure in hypertensive heart disease. Inhibition of RAAS by angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor (AT1) blockers reduces LV mass, cardiovascular events and incidence of atrial fibrillation in patients with hypertension and LV hypertrophy. Thus, in patients with LV hypertrophy, diastolic dysfunction or heart failure blood pressure should be tightly controlled by medical treatment usually including an ACE inhibitor or AT1 receptor antagonist although to date prognosis was not shown to be improved by RAAS inhibition in randomised studies including patients with heart failure and preserved ejection fraction.